PBIRJV RTI. WOI5 in Pqj&TO RICO

PUBLIC HEALTH REPORTS VOL.XXVM. DECEMBER 12, 1913. No. 50. PBIRJV RTI. WOI5 IN PQj&TO RICO. A OF I=WNOWK or MJNWI''l I WOPICAL M _DW AND TGYW4 0P 1PORTO 0ICO, By W. W. K1r, Surgeon, United States Public Health Service. The following is a report of the work in which I have been engaged, as a member of the Institute of Tropical Medicine and Hygiene of Porto Rico, from the beginning of my connection with it until October 31, 1913. For the better understanding of the inustitute and its purposes I shall give the following synopsis of its orgAnization and history: It was organzed uuder the provisions of an act of the Legislative Assembly of Porto Rico, dated March 13, 1913. It was planned and organized by Maj. Bailey K. Ashford, Medical Corps, United States Army; Dr. W.F. Lippitt, director of sanitation of Porto Rico; Dr. Pedro Gutierrez Igaravidez, of San Juan; and Dr. Isaac Gonzalez Martinez, director of the biolo_gical laboratory, service of sanitation of Porto Rico. Dr. Francisco Hernandez was selected for secretary of the institute. Dr. Lippitt, as director of sanitation, is ex officio administrator .of its funds. Inasmuch as he and Dr. Hernandez can not take an active part in the scientific work of the institute, a purely technical commission was selected for that purpose consisting of the other members and Maj. Ashford. Mai. ahford is not a men4er of the institute, but has been detailed by tbhp Surgeon General of the Army as a board, consisting of -one member, "for the study of tropical diseases as they exist in Porto Rico." He decided to work in conjunction with the technical com- mnission and was elected a member of that commission by the other member. Dr. khford and the writer are not at all concerned with the administration of the institute, but co fine themselves entirely to the scientific w-ork of the technical conzission. At the policitation of the members of the institute, the governor of Porto Rico requested the Surgeon General of the Public Health Service to detail me as a member of the institute. In order to carry out thi4 request, I was detailed as chief quarantine officer of Porto Rico and lter as member of the institute. I arrived in Porto Rico September 4, but was too occupied with quarxtine matters to do any work wit),h jthe iWitute until the 10th of October, when J *oWed the ow wlpaxerp at UJtuado,, whexp eadquarters had beon established for the xpeditionry work in the mountains. 190 (2681) December 12,1913 .2682 The plan of the institute work has three distinct periods: 1. Three months of teaching, instruction of sanitary officials, inspectors, etc. 2. Three months of expeditionary work in the interior mountainous districts. 3. Six months of research work at the laboratory and hospital at San Juan. Study and examination of data and specimens collected during the expedition. The permanent headquarters of the institute is located in San Juan in a new two-story cement building fronting the bay. On the adjoining grounds are 10 small cement isolation buildings of two rooms each. They were built for a quarantine hospital, but have practically been turned over to the institute by the director of sanitation. Near by is located the excellent laboratory of the sanitation service,which has also been put at the disposal of the institute by its director, who is a member of the institute. The use of these buildings and laboratory equipment will be without expense to the institute except for a share of the running expenses of the hospital. The appropriation for the institute was $20,000, which will be expended chiefly in experimental work, hospital expenses, expedition expenses, purchase of medical and other supplies, and salaries. I do not receive any salary, but will receive reimbursement for expense when traveling on business of the institute. The first three months were devoted, according to plan, to teaching. Instruction was given to 60 students selected from among the corps of sanitary inspectors of the sanitation service. It was designed not only to instruct these officials in the knowledge pertaining to their particular work, but also to determine those who were unfit for the position they occupied. It is intended by the director of sanitation to make this annual course the basis of appointment of these officials in the future. Lectures were given by Maj. Ashford on hygiene and preventive medicine, Dr. Gutierrez on epidemiology and disinfection, Dr. Gon- zalez on bacteriology and zoology, and the director of sanitationi detailed various officials of his department to lecture on sanitary engineering, veterinary inspection, chemistry, food inspection, administration and accounting, vital statistics, and sanitary laws and regulations. There is in preparation a manual in Spanish for the use of these nonmedical inspectors, the various instructors contributing chapters on their special subjects. In preparation for the three months expedition, lists of medical and surgical supplies were carefully prepared gnd ordered from the United States. Slow deliveries from some firms delayed the start of the expedition. 2683 December 12, 1913 This expedition had three aims: 1. Study of the diseases prevailing in the interior. 2. FEtablishment of a rural ambulant medical service. 3. Education of both planter and peon in elementary hygiene and sanitation. In the fist place, there are undoubtedly many tropical and other diseases occurring more or less frequently in Porto Rico but which while known to exist in other places- have never been identified in Porto Rico. There are others such as schistosomiasis, sprue, etc., which present many unsolved problems of interest and importance. Research along these lines is one of the prime objects of the institute. The second object is one of immense importance to Porto Rico. The rural population of Porto Rico, according to the census of 1910, was 79.9 per cent of the whole. Of these it is estimated by various observers that from 50 to 70 per cent are in need of medical attention. To meet this condition there is only the municipal physician with a very small appropriation at his command. Municipal physicians seldom make visits to the sick poor in the country. Hence the custom has arisen that if medical attention is desired, another member of the family or a friend sees the doctor in town, details,the symptoms as best he can, and carries back what medicine is prescribed to fit the apparent necessities of the patient. Sometimes the sick person is caxried long distances over mountain paths in a hammock to town, and it not infrequently happens that he must be carried home again because the hospital is already crowded. Only a few of the larger cities have good hospitals, most of them being small and poorly equipped. Under these circumstances it results that the greater part of the rural population rely upon home remedies or upon the ministrations of some person in the neighborhood who has acquired-a reputation for treating the sick. Following the work of the anemia commission (Ashford, Gutierrez, and myself) in 1904 and 1905, the insular Government has continued the appropriations for the support of the anemia service, with the result that until the present time about 300,000 persons have been treated. The dispensaries of the anemia service are located in the towns, and the same objection holds against them-that they can not reach the remoter districts of the municipalities. It is to these out-of-the-way places that the ambulant rural service will carry iedical relief. In the third place, the expedition proposes to show both planter and peon their sanitary errors, and what can be done to correct them and how to protect tl,emselves as much as possible from the communi- cable diseases to which they are -exposed. The enforcement of sanitary laws and- regulations is almost impossible until there is some December 12, 1913 2a9 general understanding of hygiene and sanitation, and some inAerest in their application. It was determined to establish 1he-expedition at some point in the mountains of the interior, to locate there a large out-patient clinic and a small hospital, and a clinical laboratory. From this eenter subclinics will be established in certain localities where a number of plantations are conveniently grouped. The equipment of the expedition consists of- 1. A portable clinical Iaboratory. 2. A large stock of drugs, mostly in tablets, instruments, and dressings. 3. A 30-bed hospital. 4. Horses and pack mules, portable medicine cases, and oases of instruments, etc. The site selected is about 1 mile from Utuado, at the coffee and sugar plantation known as San Andres. In the large country house are located thelaboratory, dispensary, examinationrooms, and quarters for the members of the technieal commission and its assistants. A two-story servant's'building was converte into the hospital-men's ward on the ground floor and women's ward on the seond floor. The location is central to a large municipality of some 40JOOO souls, and can be reached in al directions by roads and trails. Inasmuch as the material for study and research must be culled from a large number of paeients, it was very evident that some means -must be taken to attract them in large -numbers. Nothing couldserve this purpose as the opening of an "anemia station" for-the treatment of uncinariasis, more especially as this is the place where in 1904 the anemia commission inaugurated its campaign and where there is yet a lively remembrance of the benefits of treatment for this disease. The distict is still heavily infected in spite of the large number of persons who have been treated, and it was known that the opening of an anemia dispensary would -bring a great number of petients.

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